How to Appeal a Medicare Savings Program Denial in Pennsylvania

The 30-Day Deadline That National Guides Get Wrong

Federal Medicaid regulations allow states to set fair hearing windows of up to 90 days. Many national guides cite that 90-day figure. Pennsylvania doesn't use it.

Under 55 Pa. Code § 275.3(b)(1), the standard deadline is 30 calendar days from the mail date printed on the County Assistance Office notice. The CAO or Bureau of Hearings and Appeals must receive your written appeal by that deadline; the postmark does not control.

If no written notice was required, the appeal window is 60 days; if a required notice was omitted, it is six months. A request received after the applicable deadline can forfeit appeal rights for that determination.

What the Denial Notice Tells You

When the CAO denies or terminates your Medicare Savings Program (Healthy Horizons) application, it issues Form PA/FS 162. This notice contains:

• The specific reason for denial — income over the limit, resources over the limit, missing documentation, or ineligibility for the program tier you applied for
• The calculated countable income and resources the CAO used
• Your appeal rights and the hearing request deadline
• The Bureau of Hearings and Appeals address for filing

Read the income and resource calculations carefully. The most common fixable errors are: the CAO counted a disregard-eligible asset, miscalculated spousal deeming, missed the $20 unearned income disregard, or failed to deduct out-of-pocket medical expenses from countable income.

How to Request a Fair Hearing

Write a letter to the Bureau of Hearings and Appeals (the address is on your notice) stating:

• Your name, Medicaid ID number, and case number
• The date of the notice you're appealing
• That you disagree with the decision and are requesting a fair hearing
• A brief reason why (incorrect income calculation, missing disregard, documentation not considered)

Use a filing method that lets you confirm the CAO or Bureau of Hearings and Appeals received it before the deadline. You can hand-deliver it and request a date-stamped receipt, or fax it and keep the confirmation; if mailing, send it early and track delivery.

For an active case facing termination or reduction, a written appeal must be received within 10 calendar days of the notice mail date to maintain benefits while the appeal is pending. This "aid-paid-pending" protection prevents a gap in coverage during the hearing process.

What Happens at the Hearing

A hearing officer from the Bureau of Hearings and Appeals conducts the hearing — usually by phone, sometimes in person. You can represent yourself or bring a representative. The CAO caseworker presents the agency's calculation, and you present your evidence.

Bring everything: bank statements showing your actual balances, Social Security benefit verification letters, pension statements, medical expense receipts, and any documentation the CAO claims was missing. If the denial was based on an income calculation, prepare your own math showing the $20 disregard and any applicable medical expense deductions.

Free Legal Help for Appeals

The Pennsylvania Health Law Project (PHLP) at 1-800-274-3258 provides free legal representation at fair hearings for low-income Pennsylvanians. They handle Medicare Savings Program denials, terminations, and benefit calculation disputes.

PHLP has limited capacity and prioritizes cases with strong legal grounds, so contact them as soon as you receive the denial notice — not two weeks into your 30-day window.

PA MEDI counselors (1-800-783-7067) can help you understand the notice and decide whether to appeal, but they cannot represent you at a hearing.

Don't Accept a Denial Without Checking the Math

MSP denials based on income are frequently overturnable because families and even caseworkers misapply the disregard rules. The Pennsylvania Medicare Savings Programs, Extra Help & PACE/PACENET Guide includes an appeal timeline worksheet and a net income calculation tool so you can verify whether the CAO's numbers were actually correct before deciding to accept or challenge the decision.

See more Pennsylvania guides →